The European Society for Medical Oncology (ESMO) has issued new guidance on the management of breathlessness in patients with cancer.
Key recommendations in the guidance include the following:
- Patient-reported outcomes are the gold standard for assessment of breathlessness. Physiological assessments may complement but not replace patient reports (III B).
- Screen for breathlessness routinely at all inpatient and outpatient clinical encounters (III B).
- Routine screening should include a unidimensional scale of choice and activities that patients have stopped or reduced because of breathlessness (III B).
- Patients with chronic breathlessness should have a fuller assessment (IV B).
- For patients with episodic breathlessness, ask about intensity, frequency, duration, impact, and potential triggers (IV B).
- Identify and treat potentially reversible condition(s) contributing to breathlessness (II A).
For the management of conditions contributing to breathlessness, the following guide can be used.
Anaemia (symptomatic): Consider transfusion if haemoglobin
Asthma/COPD exacerbation: Medical optimisation.
Cachexia: Consider referral to palliative care, dietician, and/or physical therapy.
Central airway obstruction: For proximal lesions, consider endobronchial interventions, tumour ablation, and airway stent placement. For distal lesions, consider radiotherapy.
Chemotherapy-induced pulmonary toxicities: Withhold treatment and consider corticosteroids.
Immunotherapy-induced pulmonary toxicities: Withhold treatment and consider corticosteroids.
Heart failure exacerbation: Medical optimisation.
Lymphangitic carcinomatosis: Treat underlying malignancy. Consider corticosteroids (anecdotal).
Malignant ascites: Paracentesis with/without indwelling catheter.
Malignant pleural effusions: For patients with a short-life expectancy (
Malignant pericardial effusion/tamponade: Pericardiocentesis, pericardiectomy with/without pericardial window.
Metabolic acidosis: Identify and treat the underlying cause.
Pneumonia: Anti-infective agents.
Pulmonary embolism: Anticoagulation.
Radiation-induced pneumonitis or fibrosis: Consider corticosteroids.
Superior vena cava syndrome: Treat underlying malignancy. Consider corticosteroids (anecdotal).
Tumour embolism: Treat underlying malignancy.
- Consider use of a hand-held fan directed to the face. This may be useful alone in people without hypoxaemia, or as an adjunct to oxygen supplementation (II B).
- Advise patients on breathing retraining techniques and/or refer to specialist services (II B).
- Consider a trial of a mobility aid to assess possible impact on breathing during ambulation and functional activities (II B).
- Educate and inform patients on self-management strategies (II B).
- Refer patients to exercise-based rehabilitation programmes (I,A).
- Provide individualised advice on aerobic and resistance exercises (II B).
- Consider a therapeutic trial of acupressure or acupuncture (II C).
- Regular, oral, low-dose morphine is the first-line pharmacological treatment for severe chronic breathlessness that persists despite non-pharmacological measures (II B).
- In opioid-naïve patients, a starting daily dose of scheduled morphine 10-30 mg over 24 hours can be used, with individual titration (II B).
- In opioid-tolerant patients, an increase in the baseline dose of opioid by 25%-50% may be considered (V C).
- Consider prophylactic use of opioids in opioid-tolerant patients with severe exertional breathlessness associated with defined triggering situations leading to significant functional impairment and/or distress despite standard treatments. Patients should use prophylactic doses sparingly (≤2/day) and only with close monitoring (II C).
- All patients starting opioids should be offered prophylaxis laxatives and antiemetics as needed (I A).
- Patients should be educated on safe opioid use and monitored longitudinally with risk mitigation strategies (III A).
- Benzodiazepines should not be used as first-line pharmacological therapy (III D).
- Benzodiazepines may be used with caution for breathlessness with associated anxiety if opioids are ineffective (V C).
- In the last days of life, benzodiazepines may be considered for palliative sedation in patients with refractory breathlessness (IV C).
- Consider corticosteroids for palliation of breathlessness refractory to other treatments (II C).
- Palliative oxygen is not recommended in patients with resting SpO2 ≥90% (II D).
- High-flow oxygen may be considered, especially if the patient has hypoxaemic respiratory failure (II B).
- Consider a trial of noninvasive ventilation in patients with severe chronic breathlessness, especially in patients with acute hypercapnic respiratory failure (II B).
- Sertraline is not recommended (II D).
- The use of other antidepressants for breathlessness should be limited to the clinical trials context (V C).
- Cannabinoids are not recommended (IV D).
- Patients should be referred to specialist multimodal breathlessness services if available (I A).
- Refer to palliative care services if holistic breathlessness services are not available (II B).
- Routinely assess the psychological status, information needs, and support network for carers (III B).